PLCB-49 1/12 COMMONWEALTh OF PENNsYLvANIA PENNsYLvANIA LIqUOR CONTROL BOARd application for extension of retail license to cover additional premises (sEE INsTRUCTIONs ON REvERsE) LId NO. BUREAU OF LICENsING 1. NAME OF LICENsEE 2. TRAdE NAME (IF ANY) 3. AddREss OF PREMIsEs 4. NAME OF MUNICIPALITY (sTREET, RURAL ROUTE, P.O. BOX NO.) LICENsE NO. CONTACT PhONE NO. TYPE OF MUNICIPALITY (POsT OFFICE) (sTATE) CITY 5. NAME ANd AddREss OF OWNER OF NEW PREMIsEs BORO TWP. INC. TOWN COUNTY (ZIP) dEEd BOOK vOLUME NO. PAGE NO. / INsTRUMENT NO. 6. A. List complete information for all NEW rooms or areas. (ATTACh sEPARATE shEET, IF NECEssARY) NEW ROOM OR AREA WIdTh 11 12 13 14 15 16 17 18 19 10 LENGTh WhICh FLOOR INsIdE OR OUTsIdE BLdG. dEsIGNATEd UsE sERvING, KITChEN OR sTORAGE NEW sTREET AddREss, IF ANY B. If one of the present rooms has been enlarged, indicate by listing the line number: C. If outdoor extension, is the area to be used as a sidewalk cafe? d. Application to be considered for "Prior Approval"? If no, list municipality YEs YEs NO NO YEs NO CITY BORO TWP. Type of municipality INC. TOWN E. Is area listed in 6A in the same municipality as shown in question No. 4? F. COMPLETE ThIs sECTION FOR TEMPORARY UsE ONLY: (ATTACh sEPARATE shEET, IF NECEssARY) 1. List dates and hours business will be conducted FROM ________________TO _______________ dURING ThE hOURs OF_________ TO ________ . 2. describe the entire scope of business to be conducted on the temporary extension of premises areas listed in 6A. 7. A placard, PLCB-1296, Public Notice of Application Alcoholic Beverages, was posted on (dATE) ___________________ in a conspicuous place on the outside of the premises as required by the Liquor Code, and will remain posted until a notice of approval or refusal is received by the applicant. 8. resolUtion (corporations, limited liaBilitY companies and clUBs onlY) At a regular or special meeting held on ___________________________________ , 20___________ by the applicant, it was resolved that said application be filed with the Pennsylvania Liquor Control Board, and that ________________________________________ and/or _________________________________________ is/are hereby (NAME/TITLE) (NAME/TITLE) authorized to execute said application, and any other papers required by the Board. I swear or affirm, subject to the penalties provided by 18 Pa. C.S. §4904 and 47 P.S. §4-403(h) §4-436(j), that the foregoing answers and statements provided herein are true and complete to the best of my knowledge and belief. sIGNATURE hOME AddREss TITLE PhONE NAME OF ATTORNEY REPREsENTING YOU IN ThIs MATTER, IF ANY AddREss sIGNATURE TITLE PhONE hOME AddREss PhONE dATE sIGNEd E-MAIL AddREss do not Write BeloW tHis line American LegalNet, Inc. www.FormsWorkFlow.com instrUctions This form is to be used to report a change to or an addition to the approved licensed premises by retail (restaurant, hotel, club, eating place, brew pub and limited winery) licensees. To report an addition to an approved licensed premises by a wholesale (distributor, importing distributor) licensee, use form PLCB-1708, Application for Wholesale License to Cover Additional Premises. 1. A fee made payable to "PLCB" or "Commonwealth of Pennsylvania" of $220.00 MUsT accompany this form. Be advised that should the Board refuse the application, the fee will be retained as non-refundable. All fees submitted on behalf of an application for temporary extension will be non-refundable. 2. All questions must be answered and complete information must appear on this form. This form MUsT be signed. If the change is to the room measurements or to use of the areas, this form is required along with a set of plans showing the changes. If the change is merely cosmetic (e.g.; new carpeting or furnishings) the form is not required. New areas, not previously listed on your application, which are to be used for any one of these purposes, MUsT be listed on this extension application in answer to question #6 in the following manner: A. A description of any new room or area to be used for the preparation of food, the service of food and alcoholic beverages or new space to be used for the storage of alcoholic beverages, MUST be listed as specified in this section. B. If application is for a sidewalk cafe, it MUsT be accompanied by written permission from proper authorities of the municipality and a set of plans setting forth the dimensions, names of abutting streets and location of the principal licensed premises. C. If application is for the immediate, abutting and adjacent contiguous land, it MUST be accompanied by plans or surveys setting forth the dimensions, names of abutting streets and location of the principal licensed premises. Plans must be on 8½" x 11" paper and must be clear and readable. D. The application may be filed before physical alterations or new construction is begun by checking "yes" to prior approval. This application MUsT be accompanied by a site plan clearly showing the premises as it will be after completion, on 8½" x 11" paper depicting the location of the proposed premises in relationship to identifiable lines or easily identifiable landmarks or reference points with measurements to the property lines, landmarks or reference points. The plans must be clear and readable. E. If the extension of the licensed premises is to be for a limited period of time, the temporary dates of use must be completed. The application MUST be filed at least 30 days prior to the scheduled date of temporary extension and MUsT describe the entire scope of business to be conducted at the temporarily extended premises and include the specific dates and hours business will be conducted. Application MUST be accompanied by plans/surveys setting forth the dimensions, names of abutting streets and location of the principal licensed business, on 8½" x 11" paper. Each plan must be clear and readable. 3. A Placard, PLCB-1296, Public Notice of Application Alcoholic Beverages, MUsT be posted on the licensed premises, except for Limited Winery Licensees. 4. PLCB-193, Affidavit of Compliance, regarding the notice of posting must be completed and submitted. information a. No additional premises shall be used by any licensee until approved by the Board. b. The premises covered by the license for the retail sale of liquor and/or malt beverages include the rooms wherein food and alcoholic beverages are served and consumed, the separate kitchen, if any, and areas used for storing liquo